Evidence-Based Interventions in Autism

INTRODUCTION

Primary care pediatricians have a crucial role in screening for autism and other intellectual and developmental disabilities¹ and providing longitudinal care to children with autism spectrum disorder (ASD) and their families. This review provides an overview of evidence-based treatments to support optimal developmental-behavioral outcomes and independent living skills for children with ASD. The review is organized by treatment domains (ie, early intervention, communication, adaptive skills, and so forth) and within those domains information is presented by general age groups (ie, toddlers, preschoolers, adolescents).

Autism is a heterogeneous diagnosis including individuals with a wide range of intellectual abilities, communication skills, and associated behaviors. Every child with ASD has a unique set of strengths and challenges and there is no “one size fits all” model for treatment. Intervention recommendations should be customized to best meet the needs of each child, align with a family’s goals and priorities, and be feasible for the child and family in terms of time and cost. Families seeking care for autistic children may be inundated with information about therapy options of varying levels of evidence. Pediatricians play an important role in advising families that they are likely to hear about interventions for autism that are both evidence-based and non-evidence based. Conversations between pediatricians and families about ASD treatment choices can be enhanced using a shared decision-making approach. This allows the clinician to provide evidence-supported information and to identify a family’s goals, priorities, and values to ensure that the treatment plan is a good fit for the child and family. When making decisions about their child’s treatment, families should understand which practices have clear evidence of positive outcomes based on multiple research studies. To address the need for evidence-based practice guidelines for ASD based on systematic review of the literature, the National Autism Center published the National Standards Project (NSP2, published in 2015)² and the University of North Carolina National Clearinghouse on Autism Evidence and Practice (NCAEP) Review Team published an Evidence-Based Practices report in 2020.³ Both reports provide comprehensive and detailed information about ASD evidence-based interventions and associated outcomes. The findings from these reports are reflected in this review article.

Pediatricians play an important role in encouraging early diagnosis and intervention, advising families about evidence-based treatments for ASD, and supporting family’s emotional health as they care for a child with a developmental disability.⁴ The purpose of this article is to provide pediatricians with information about evidence-based autism treatments.

DISCUSSION

Importance of Early Intervention

Autism can be diagnosed with accuracy in children less than 2 years of age⁵ and when possible, the goal is to diagnose children before 3 years of age.⁶ The rationale for encouraging early identification and diagnosis of ASD is that interventions started before age 3, at a time when the brain is still developing and has more plasticity, are more likely to be effective long-term.⁷ The use of evidence-based early intervention (EI) services that promote building developmental skills sequentially and positive parent-child interactions improves outcomes.^8–10 Unfortunately, common misconceptions such as giving it more time with a “wait and see” approach or that young children with developmental delays will “catch up,” can lead to delays in referrals to services¹¹ and lost opportunities for intervention during critical windows for development. Several EI treatment models offer clear benefits to autistic children less than 3 years of age.⁵

Goals of Intervention Across the Lifespan

Younger age at enrollment into EI services has been associated with achieving greater gains in social communication, cognitive abilities, adaptive skills, and reduction of ASD symptom severity.¹² There is a greater positive impact from interventions started before age 3 years compared to those started after age 5 years.^5,13,14 However, intervention services are beneficial for children with ASD at any age and can be started as soon as an ASD diagnosis is suspected or diagnosed. Treatment goals for children with ASD include (1) minimizing impact of challenges associated with core ASD symptoms (social communication difficulty, restricted interests/repetitive behaviors); (2) maximizing functional independence/adaptive skills; and (3) preventing, reducing, or minimizing the impact of behaviors that interfere with acquisition of functional skills.¹⁵ Intervention services need to be individualized to the specific child’s strengths and areas of difficulty and aligned with families’ goals and priorities. Shared decision-making between clinicians and families can be used to determine the best fit for a child’s participation in therapy services. Clinicians should provide information about evidence-based treatment options and consideration should be given to families’ sociocultural beliefs, family dynamics and support system, health insurance coverage for treatments, and the family’s economic situation, all of which can impact the feasibility of participation in therapy.^5,15

Determining a treatment plan for a child with autism requires an understanding of evidence-based interventions, the family’s goals and priorities, and the unique strengths and needs of the child. Goals and needs may change over time and vary based on the child’s developmental stage. Table 1 provides information about potential evidence-based therapy options.

Table 1.

Intervention services for children with autism

Service/Therapy	Developmental Domains Targeted	Age Range	Funding Source(s)	Intervention Approach & Additional Information
State Early Intervention Services (IDEA part B)	Cognitive Communication Motor Adaptive Social-emotional	0–3 ys	Public Public or private health insurance (for some programs)	IFSP based on child’s needs which then determines goals and services Parent training model Professionals: developmental specialist, speech-language pathology, PT, OT
Public school education services (IDEA part C)	Academic Cognitive Communication Social Motor Adaptive Behavior	3–21 ys	Public	Eligibility for IEP based on multidisciplinary evaluation determining if child meets criteria for disability category with impairment impacting education. IEP based on child’s needs which then determines goals and services Professionals: special education (intervention specialist), speech-language pathology, PT, OT, behavior support, school psychologist
Comprehensive treatment models (CTMs) based on principles of ABA (ie, EIBI, ESDM) Outpatient therapies (domain-specific)	Behavior Cognitive Communication Social Adaptive Academic	0–9 ys	Public or private health insurance-Private pay	Center-based or home-based programming Follows manualized procedures Goals determined based on skill acquisition Frequency: substantial number of hours/week Longevity: treatment for 1 y or longer
Speech-language therapy	Communication- receptive, expressive, pragmatic language, social skills	All ages	Public or private health insurance Private pay	Evidence-based strategies include augmentative and alternative communication (AAC), functional communication training, language training, modeling, scripting Emerging evidence for virtual or augmented reality (VAR) interventions
Behavioral—mental health treatment	Behavior Emotions (eg, anxiety) Adaptive Social Executive functioning	All ages	Public or private health insurance	Parent-management training to address behaviors Cognitive-behavioral therapy for school-aged and adolescent children with adequate communication and cognitive skills Professionals: psychology, licensed clinical social worker, counselor, behavior therapist
Occupational therapy	Fine motor skills Gross motor skills Sensory processing Adaptive	All ages	Private pay	Ayres Sensory Integration® approach is evidence-based to improve sensory integration Treatment may address adaptive behaviors such as feeding and toileting
Social skills intervention	Social	Adolescents	Public or private health insurance	PEERS—evidence-based, manualized social skills intervention Professionals: speech-language therapist, psychologist, licensed clinical social worker

Abbreviations: ABA, applied behavioral analysis; EIBI, early intensive behavioral intervention; ESDM; early start Denver model; IDEA, individuals with disabilities education act; IEP, individualized education program; IFSP, individual family service plan; OT, occupational therapist; PT, physical therapist.

Federally Mandated Interventions and Services in the United States

Note: this section describes EI and educational services that are federally mandated in the United States and, therefore, may not be applicable in other countries. In 2012, guiding principles were published to support the international community to develop or refine EI programs to yield optimal outcomes for children with developmental delays/disabilities consistent with 2 United Nations international human rights treaties: the Convention on the Rights of the Child and the Convention on the Rights of Persons with Disabilities.¹⁶

The Individuals with Disabilities Education Act (IDEA) authorizes federal funding to states to support EI services for infants and toddlers from birth up to 3 years (part C) and special education services for preschool and school-aged children of 3 to 21 years (part B).¹⁷ This is also discussed in the article Autism Spectrum Disorder at Home and in School.

Early intervention (part C): birth to age 3 years

Participation in EI services for infants and toddlers with developmental delays is associated with positive long-term outcomes in language, cognition, academics, and behavior.⁸ An Individual Family Service Plan (IFSP) is developed by the EI professionals with family input documenting the child’s goals and services. Best practices for EI services include creating opportunities for “learning in the natural environment” and using a family “coaching” model.⁸ The contact information for every state’s EI program can be found on the Centers for Disease Control and Prevention (CDC) website: https://www.cdc.gov/ncbddd/actearly/parents/state-text.html. The CDC’s “Learn the Signs. Act Early.” Program¹⁸ provides resources to parents to track developmental milestones and learn more about EI services.

Part B services: preschool-aged and school-aged services

Preschool-aged children (3–5 years old) with ASD can be referred to their public school district for evaluation for eligibility for special education preschool services (part B). For children less than 3 years receiving EI services, the IFSP team will orient families and facilitate the transition of supports to part B special educations services.¹⁷ Preschool-aged (3–5 years) and school-aged children (6–21 years) referred to the school district will undergo multidisciplinary team evaluations to determine eligibility for Individualized Education Program (IEP) services. Eligibility for an IEP is based on the child meeting criteria for a categorical determination of a disability as defined by IDEA (such as autism, intellectual disability, speech or language impairment, other health impairment, and so forth) and this condition affecting school performance and learning.¹⁷ If eligible, children can begin to receive services once an IEP is developed. The IEP documents goals and services and is developed with family input. Parents can choose to share independent diagnostic evaluation or therapy reports with the school district to support the development of IEP goals.

EVIDENCE-BASED INTERVENTIONS

Core Autism Spectrum Disorder Symptoms

For children less than 3 year old with ASD, best practice involves participation in interventions starting as early as possible that include a combination of developmental and behavioral approaches, meaning therapies that are evidence-based and are adjusted to the child’s developmental level and use behaviorally based strategies and teaching methods.⁵ Evidence-based interventions for autism treatment are described in 2 categories: (1) comprehensive treatment models (CTMs) and (2) evidence-based practices (EBPs) or focused intervention practices.^3,19–21 Both CTMs and EBPs are effective across a range of ages and developmental levels, although CTM programs target building essential skills for younger children (0–9 years of age).² Additionally, participation in outpatient therapies (described in following paragraph #3) such as speech-language therapy, occupational therapy (OT), and behavior therapy can support skill development to address common symptoms of autism (ie, communication difficulty) and co-occurring developmental delays/disabilities or behavioral challenges.

Comprehensive treatment models: target age range 0 to 9 years

CTMs include intensive EIs that address skills important for early childhood development including communication, social, and adaptive skills. CTMs are based on a conceptual framework that supports broad learning and skill development to impact core features of ASD.²⁰ Additionally, CTMs are characterized by the use of manualized procedures, intensity (substantial number of hours per week), longevity (treatment occurs for 1 year or longer), and a focus on broad outcomes (ie, communication, behavior, social).³ CTM programs may use approaches of applied behavioral analysis (ABA) and/or naturalistic approaches (strategies provided in the context of typical social activities in community settings).¹⁵ Examples of CTM programs include Early Intensive Behavioral Intervention (EIBI), Treatment and Education of Autistic and Related Communication-Handicapped Children, the Early Start Denver Model, or similar behavioral inclusive programs.^2,15 Table 2 describes characteristics of several CTMs. These programs use similar evidence-based strategies such as using a visual schedule to communicate the activities that the child will be doing and providing reinforcement when a child is learning a new skill. In addition to building developmental skills such as self-feeding using utensils or toilet training, CTM programs integrate behavioral approaches to increase or decrease target behaviors. There is no evidence to support which specific CTM approach is the best fit for each child. There are also regional differences in the availability of programs. However, pediatricians can confidently recommend these evidence-supported CTMs (see Table 2) and should encourage families to choose a program based on their goals, preferences, and factors such as availability and cost.

Table 2.

Examples of comprehensive treatment models including evidence-based practices

Model/Intervention	Domains Addressed	Setting	Approach/Program Characteristics
Comprehensive treatment models (CTMs)
Early Intensive Behavioral Intervention (EIBI)	Addresses core autism spectrum disorder (ASD) symptoms (social-communication, restricted interests, play, imitation)	Structured, predictable setting, low student-to-teacher ratio	Program supports acquisition, generalization, and maintenance of developmentally appropriate skills Monitors progress over time Uses Discrete Trial Training (DTT) (ie, an instruction is given, child responds, a planned consequence is provided, and a pause before presenting next instruction) Promotes family involvement Implements functional approach to challenging behaviors
Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)	Targets activities of daily living, communication, social skills, executive functioning, attention, engagement. Skill acquisition in these domains supports intellectual functioning.	Structured setting, environment organized to meet child’s needs (ie, minimize distraction), predictable setting	Individualized curriculum developed based on individual’s abilities and needs as measured by standardized assessments Makes use of structured teaching experiences Organize tasks/materials to promote independence from prompts, including use of visual supports (ie, visual schedules, video modeling) Encourages close working relationship between practitioners and parents
Naturalistic developmental behavioral interventions (NBIs)— These use strategies involving naturally occurring environments and activities
Early Start Denver Model (ESDM)	Designed for young children (12–48 mos); addresses core autism spectrum disorder (ASD) symptoms; supports social, communication, cognitive skills	Multiple settings—home, school, clinic; as a group or one-on- one	Parents and therapists use play to build positive, fun relationships while targeting developmentally appropriate skills Based on understanding of toddler development and learning Teaching occurs in natural, everyday settings/activities
Pivotal response treatment	Addresses “pivotal” areas of development: motivation, response to cues, self-management, and initiation of social interaction	Multiple settings- particularly natural environments (school, community)/inclusive settings with typically developing peers	Parents taught to implement motivational procedures including: following child’s lead, offering choices, gaining child’s attention, providing opportunities to respond/take turns, varying tasks, using natural reinforcement, reinforcing attempts at target skills Family involvement is emphasized
Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER)	Play-based intervention, teaches social communication skills to young children (12 months- 8 ys)	Multiple settings—inclusion/special education classrooms, home, community	Interventions focused on 4 core domains: Joint attention—teach and model coordination of attention between objects and people for purpose of sharing Symbolic play—model appropriate play, increase flexibility in play, support joint attention in play Engagement—joint engagement with others Regulation—of emotions/behavior

Evidence-based practices (also called focused intervention practices): all ages

EBPs are strategies designed to teach an individual skill or to address a specific goal.^19,21 EBPs are the basic units or building blocks that are combined to form educational programs for children with ASD including CTMs, public school special education interventions, and outpatient therapies.^20,21 Some examples of EBPs are discrete trial training (an instruction is given, child responds, a planned consequence is provided, and a pause before presenting next instruction), prompting (verbal or gesture assistance given to learner to support acquiring a skill), video modeling (video-recorded demonstration of a target skill is shown to learner), and visual supports (visual display to support learner engage in behavior without additional prompts).²¹ These focused interventions can be used for short periods of time, until a specific goal is achieved, and may address skills in the areas of behavior, development, or education.

Outpatient therapies: all ages

Children with ASD benefit from participation in outpatient therapies delivered by licensed professionals to support skill development across multiple domains. Examples of outpatient therapies include speech-language therapy, OT, and behavior therapy. Children receiving part C or part B services (EI or school-based services) can supplement these interventions with outpatient therapies to provide increased frequency and intensity of intervention and address goals impacting the child outside of the educational setting (ie, difficulty getting haircuts, tantrums when transitioning from activity to another). Caregiver involvement and practicing specific skills at home and within the community are critical components for the success of outpatient therapies. For example, if a child is learning to use 1 to 2 word phrases to request or make choices in speech therapy, the caregiver should work on practicing this skill at home (eg, choosing what snack the child wants, choosing what toy the child wants to play with) and within the community (eg, choosing a book to check out at the library, choosing a cereal to buy at the grocery store). The role of outpatient therapies will be described in each developmental domain section in the following paragraphs (ie, social communication, adaptive, behavior). Of note, for some children, outpatient therapies are not a feasible option due to challenges such as lack of access to pediatric therapists, long wait times, and financial barriers (limited insurance coverage, high co-payment fees).

Applied Behavioral Analysis and Early Intensive Behavioral Intervention

Principles of ABA are the foundation for most evidence-based treatment models for autism. ABA is a general behavioral learning theory, not a specific set of interventions.²² ABA has been defined as the process of applying learning theory principles to improve socially meaningful behaviors and evaluating if changes in behavior are due to the interventions.²³ ABA methods can include reinforcing social, communication, and other skills and are effective at reducing challenging behaviors that may interfere with a child’s progress toward educational or independent living goals.^15,22 The goal of ABA is to promote meaningful growth in skill development (eg, adaptive skills, functional communication, emotional regulation) and generalize skills across environments (eg, community, home, school, different caregivers). EIBI programs, which are CTMs using ABA principles, have demonstrated positive outcomes, including 20% to 50% of children participating in EIBI programs achieving average intelligence quotient and placement in general education settings upon completion of treatment and 20% to 40% achieving moderate gains, but still requiring supports.^13,22

ABA therapy can be delivered in a variety of settings including 1:1 or group settings, center-based, or in more natural environments (home, school). An individualized treatment plan should be developed collaboratively between the family and the professional supervising the child’s ABA therapy program, typically a board-certified behavior analyst, to address identified priorities.

Naturalistic Developmental Behavioral Interventions

Naturalistic developmental behavioral intervention (NDBI) approaches foster back-and-forth engagement between the child and the intervention provider.¹² The intervention provider responds to the child’s interests, play, and communication approaches in an intentional way (eg, reading the child a book after a child points and requests it). Cues are provided to the child to promote behaviors with consequences naturally found in the environment providing reinforcement.^2,12 Naturalistic interventions can be incorporated into typical activities and routines to support and encourage learners to build and promote skills in natural and contextually relevant environments, such as home, school, and the community.^2,3,12

Parent-Mediated Intervention

Parent-mediated intervention, also called parent training, describes a variety of approaches in which parents receive training to implement strategies to promote building their child’s social communication skills or reducing challenging behaviors.^2,3,15 Parent training can occur individually or in group settings and can provide strategies to target core ASD symptoms (eg, building expressive language and joint attention skills) to teach new skills to a child (eg, engaging in play with other peers) or to reduce disruptive behaviors.

SOCIAL COMMUNICATION

Building communication and social skills is a key focus of interventions for children with ASD from the toddler/preschool years through adolescence. Interventions supporting communication are generally delivered by speech-language pathologists and those supporting social skills can be delivered by professionals in multiple disciplines, including speech-language pathology, psychology, special education, and OT.

Toddlers and Preschool-Aged Children

When toddlers and preschoolers are diagnosed with ASD, they may have no or limited verbal language and no or limited means of functionally communicating their needs and wants (eg, requesting items, asking for help). Developing both areas is critical at this age, especially the latter. Evidence-based strategies that target communication skills include behavioral interventions, naturalistic teaching strategies, functional communication training, language training (production), modeling, scripting, and augmentative and alternative communication (AAC).^2,3

Communication goals can be incorporated into treatment programs utilizing behavioral interventions or naturalistic teaching strategies. Functional communication training, as a circumscribed intervention, is complementary to these strategies. It seeks to identify problematic behaviors in a child that serve a communication purpose and replace them with more appropriate means of communication, for example, verbal language or AAC. Language training (production) centers on helping autistic children use their spoken words functionally. Modeling and scripting are ways a desired behavior or response to social situation can be modeled for children with ASD. With scripting, a verbal script for a specific social situation is modeled for and practiced with the child. Given the range of evidence-based strategies available, it is beneficial for children with ASD to have a speech-language pathologist with competencies in ASD as part of their larger treatment team.

AAC focuses on the use of communication systems that do not rely on verbal language, including sign language, Picture Exchange Communication System (PECS), and speech-generating devices (SGDs). Across these approaches, the use of PECS and SGDs, compared to sign language, has been found to be more effective in building fundamental communication skills, like requesting.²⁴ Effectiveness of AAC is enhanced when it is used to teach communication skills in specific routines (eg, mealtimes).²⁵ Many parents express concern that using AAC will prevent their child from developing verbal language. Contrary to this belief, studies have shown that AAC does not impede verbal language and may increase it modestly. More research is needed on child and treatment (frequency and intensity of intervention) factors that influence outcomes with AAC.²⁶

The evidence-based strategies described earlier are also effective for building social and play skills (eg, imitative play, make-believe play, turn taking with peers and adults) in toddlers and preschoolers with ASD. Additionally, parent training, peer-mediated interventions, and social narratives are effective in building these skills.^2,3 Social narratives have similarities with modeling and scripting. They utilize visuals and/or written words to describe to the child what they can expect of a specific social situation and how to respond to it. There is emerging evidence for interventions centered on specific social communication skills like imitation, eye contact, gestures, joint attention, and play.^27,28 THe effect sizes for this intervention are moderate and enhanced for children of younger ages with higher dosage of treatment.

School-Aged Children

For school-aged autistic children, the same evidence-based strategies utilized to promote communication and social skills in toddlers and preschoolers with ASD are applicable. Peer-mediated interventions in home or school settings may be more impactful. Peers are trained in how to respond during social interactions with the child who has ASD (eg, engaging in back-and-forth conversation, taking turns playing a game). These interventions have been shown to increase frequency and duration of social interactions, as well as help build the use of AAC.²⁹ It is unclear if they have impact on verbal language.

Adolescents

In adolescents with ASD, the following evidence-based strategies remain effective for promoting communication and social skills—modeling, scripting, AAC, parent training, and peer-mediated interventions. Additionally, social skills packages are an effective, evidence-based strategy for this age group.^2,3,30 This intervention centers on helping a teenager with ASD build skills needed to participate in social experiences across settings, namely, home, school, and in the community. The Program for the Education and Enrichment of Relational Skills (PEERS) is a manualized social skills intervention package for autistic adolescents and young adults that has been designated as evidence-based in increasing specific social skills^31,32 (eg, reciprocal conversations, interactions with same-aged peers, etc.) both immediately after treatment and at follow-up. PEERS for adolescents consists of 14 weekly and concurrent sessions for both adolescents and their parent/caregiver. In the adolescent group, evidence-based strategies such as direct instruction, modeling, video modeling, and reinforcement are used to teach concepts such as having a back-and-forth conversation, dealing with teasing and bullying, and hosting a get-together for a friend. In the caregiver group, caregivers receive instruction on what the adolescents are learning and also receive coaching on how to provide feedback to adolescents during weekly homework assignments (eg, joining a club or activity, having a friend over, and so forth). Research has shown that many social skills packages have a positive impact on their social knowledge, but it is unclear how much it improves their participation in social activities.³⁰

Lastly, there is growing research on extended reality interventions, for example, virtual or augmented reality (VAR) environments, for child and adolescents with ASD. In studies of VAR interventions, the effectiveness of this intervention ranges from weak to strong for promoting social skills.^33,34 Older age was found to contribute to larger improvements, while the presence of comorbid conditions was found to contribute to smaller improvements.

It is important to note that, sometimes, families seek interventions that are not evidence-based. Currently, facilitated communication and rapid prompting method do not have an evidence base for building communication and social skills in children with ASD. They are also not supported by the American Speech-Language-Hearing Association.³⁵

ADAPTIVE BEHAVIOR

Adaptive behavior is defined as the ability of an individual to be independent and self-sufficient in the areas of communication, socialization, and daily living skills.³⁶ The authors will focus on daily living skills in this section since communication and socialization are covered in other sections of this review. Daily living skills are the everyday tasks and behaviors an individual does to take care of themselves at home, school, work, and in the community and are categorized into personal/self-care (eg, getting dressed, brushing teeth, showering, taking medications), domestic (eg, picking up belongings, cleaning one’s room, cooking meals, doing laundry), and community (eg, telling time, buying items at the store, getting around the community, and managing and budgeting money).³⁷ Interventions supporting adaptive skills can be delivered by professionals in multiple disciplines, including OT, psychology, and special education.

Toddlers and Preschool-Aged Children

Daily living skills that are critical for toddlers and preschoolers include getting dressed, eating and drinking, basic personal hygiene (eg, washing hands, brushing teeth), toileting, and simple household chores (eg, picking up toys). Increased age, higher cognitive abilities, few behavior problems, and less severe ASD symptoms are associated with better daily living skills in this age group.³⁸ Preschool children with autism demonstrate a significant gap between their chronologic age and daily living skills, which suggests these skills need to be prioritized in intervention to increase the likelihood of attaining positive outcomes in adulthood.^38,39 Evidence-based interventions for this age range are typically behavioral (eg, discrete trial training, extinction, reinforcement, prompting), and may also include video modeling, visual supports, social narratives, or the use of technology.³ It can be highly beneficial for caregivers to work with psychologists or occupational therapists to develop goals and implement evidence-based strategies when targeting the acquisition and mastery of these skills.

School-Aged Children

Daily living skills that are critical for autistic school-aged children include hygiene (eg, taking a bath or shower), cooking snacks and simple meals, helping with their laundry, cleaning their room, understanding the concept of time, and developing an understanding of spending and saving money. The gap between chronologic age and actual daily living skills continues to widen as children start school, which makes it critical to intervene.^39,40 While many evidence-based strategies to address age-appropriate daily living skills continue to be behavioral (eg, reinforcement, prompting), additional strategies such as task analysis and cognitive behavioral intervention strategies may be useful. For example, if a school-aged child is struggling to complete their morning hygiene routine before school, this skill could be explicitly broken down into its component steps (eg, wake up with alarm, get dressed, put pajamas in hamper, brush teeth, comb hair, and so forth) using a task analysis and then used as a checklist to help them consistently and independently complete this routine (Fig. 1). The child could then be rewarded (eg, verbal praise, 10 minutes of screen time before school) for completing the routine independently or with minimal prompts from a caregiver.

Fig. 1.

Example of visual schedule for morning routine.

Adolescents

Daily living skills that are essential for continuing to build independence and autonomy prior to the transition to adulthood include personal care and hygiene (eg, wearing deodorant, taking medications, beginning to manage health care appointments), cooking meals, cleaning the home (eg, vacuum/mop, taking trash out), household maintenance (eg, cutting the grass), managing money (eg, budgeting for expenses), and navigating the community (eg, biking, walking, driving). The gap between daily living skills and chronologic age is often very apparent in adolescence such that a teen’s skills may be 6 to 8 years behind their peers,^41,42 which then directly affects their ability to achieve positive adult outcomes in college, employment, independent living, and quality of life.⁴² Evidence-based strategies such as prompting, reinforcement, visual supports, and task analysis continue to be effective for teaching these skills. However, additional strategies such as self-monitoring and technology-aided instruction may be particularly effective in adolescence. For example, surviving and thriving in the real world is a manualized intervention that has shown promise in increasing age-appropriate daily living skills in autistic adolescents in the areas of hygiene, laundry, cleaning, cooking, and managing money.⁴³ An essential intervention component is the use of a contract to define specific daily living skills goals and expectations, monitor daily/weekly progress, and specify the reward or privilege that will be earned. Technology strategies such as alarms (eg, to switch laundry from the washer to the dryer) or reminders (eg, setting a smart speaker to remind the teen to take medication at 7:45 am everyday) are often incorporated to build autonomy.

BEHAVIOR AND MENTAL HEALTH

While disruptive behaviors are not a core feature of ASD, it is common for children with ASD to experience challenging behaviors such as inattention, hyperactivity, impulsivity, anxiety, irritability, tantrums, refusal behaviors, aggression, and self-injury.⁴⁴ In a population of about 600 children with ASD from 13 sites across North America participating in an autism learning health network, 93% of parents of children of ages 6 to 12 years reported problematic behaviors in the past month, with 85% indicating these behaviors were of moderate or worse intensity (moderate [47%], severe [28%], or extremely severe [10%]).⁴⁴ Co-occurring psychiatric conditions occur in up to 70% of children with ASD.⁴⁵ Attention-deficit/hyperactivity disorder (ADHD), anxiety, and oppositional defiant disorder are among the most commonly reported conditions⁴⁵ and 41% to 61% of children with ASD have 2 or more psychiatric conditions.⁴⁶

Identifying Triggers and Patterns of Challenging Behavior

Conducting a functional behavioral assessment (FBA) is the first step to developing an effective intervention plan to address challenging behavior. The FBA involves observation and data collection to identify the “ABCs” of a behavior—the antecedent (what happens before the behavior), the behavior of concern, and the consequence (what happens after the behavior). These data are then used to determine the function of a maladaptive behavior (why is the child engaging in the behavior?) to determine how to respond to the behavior to make a change and disrupt the persistence of the behavior. Common functions of behavior include wanting to get something, such as attention or a tangible object, or wanting to escape something. Sometimes it can be difficult to identify the function of a behavior. If disruptive behavior seems to occur “out of the blue,” without an identifiable trigger, it is important to evaluate for possible underlying medical reasons for the behavior such as pain, dental problems, sleep disorders, or constipation, for which children with ASD are at increased risk.^47,48 Additionally, clinicians may want to consider evaluation for a possible co-occurring mood disorder. The FBA approach can be used in therapy and school/classroom settings to develop effective behavior plans.

Behavior and Mental Health Interventions

Parent training

Parent training models are an evidence-based intervention for the treatment of disruptive behaviors including ADHD in typically developing children. These include programs such as Incredible Years, Positive Parenting Program, and Parent-Child Interaction therapy.^49–51 Through participation in these programs, parents gain an understanding of the child’s behavior and skills to respond to the child and reinforce desired behaviors. However, less is known about the effectiveness of parent-mediated interventions in children with developmental disabilities including autism.⁵² While parent training was found to be superior to parent education in reducing disruptive behavior in a randomized control trial,⁵³ a 2020 systematic review and meta-analysis of parent training for children with ASD concluded that methodological limitations make it difficult to draw conclusions about effectiveness and generalizability of specific parent training programs at this time.⁵⁴

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is an effective treatment for pediatric anxiety disorders in the typically developing population, with approximately 60% of children rated as much improved or very much improved on the Clinician Global Impression-Improvement Scale after 14 sessions of CBT.⁵⁵ Systematic reviews have found moderate efficacy of CBT for the treatment of anxiety in autistic youth without an intellectual disability.^56,57 Manualized CBT intervention programs have been adapted to meet the needs of individuals with ASD, including adjustments to materials to provide visual cues and role-playing.² CBT interventions teach participants to evaluate their thoughts and emotions and then use step-by-step strategies to change their thinking and behavior.³ These interventions can be helpful at addressing challenging behaviors related to emotions such as anger and anxiety.³

Facing your fears

Facing Your Fears (FYF) is a cognitive behavioral intervention for autistic school-aged children (ages 8–14) that uses evidence strategies to increase recognition of anxiety symptoms (eg, thoughts, feelings, physical reactions) and then teaches a range of age-appropriate coping strategies (eg, worry bugs, exposure strategies). FYF sessions are attended by both children and their caregiver, and they then break into separate groups to allow for additional instruction, practice, and coaching. In particular, caregivers are coached to provide supportive feedback and support as their child learns how cope with their anxiety and generalize these skills to other settings (eg, school, social interactions with peers).⁵⁸

Additional evidence-based strategies

For children who do not have the cognitive or communication skills to participate in CBT, other evidence-based strategies and tools can be helpful for reducing stress and anxiety such as use of visual supports. Visual supports provide information in a visual format, which can include photographs, pictures, or checklists that may or may not be paired with words (eg, listing the steps for calming down when feeling frustrated or anxious). Visual schedules are a type of visual support that prepares children to participate in an activity or routine by providing information about what to expect, including what they need to do, what will happen as a result, and when the activity will be done.³

Executive Functioning

School-aged and adolescents

It is estimated that between 35% to 70% of autistic children and adolescents have significant challenges in the area of executive functioning, which includes skills such as organization, planning, prioritizing, time management, initiating tasks, persevering on tasks, completing tasks, multitasking, and working memory.⁵⁹ Executive functioning impairments have been shown to impact performance at both home (eg, completing homework assignments, getting household chores done) and school (eg, writing down assignments in a planner, taking notes, bringing materials to class) and are also predictors of poor outcomes in adulthood.⁶⁰ The profile of executive functioning in autistic individuals appears to be similar to those with a diagnosis of ADHD⁶¹ and they may benefit from similar treatments. For example, several evidence-based supports and strategies (eg, task analysis, graphic organizers, technology such as alarms and reminders) and interventions (eg, Unstuck and On Target, Achieving Independence and Mastery in School) have been identified to be implemented at both home and school to address specific executive functioning difficulties in autistic individuals.^3,62 Children and adolescents may benefit from attending group or individual treatment to learn compensatory strategies (eg, using a binder to organize classroom materials, creating flash cards to study) to address executive functioning challenges. Caregivers are often an integral component of treatment so that they can assist their child in implementing specific strategies (eg, writing down and prioritizing assignments in a planner) at home and school.

Sensory processing

Many children with ASD have difficulty with sensory processing. Hyperactivity or hyporeactivity to sensory input or unusual sensory interests in aspects of the environment is one of the restrictive, repetitive patterns of behavior symptoms included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria for ASD.⁶³ In children with ASD, sensory processing difficulty can present with a range of behaviors such as food selectivity and restricted eating habits, sensitivity to loud or unexpected noises (covering ears, becoming upset), visual examination (looking at objects out the side of the eye, visual fixation on spinning objects or lights), or tactile sensitivity (not liking how it feels to wear clothes or shoes). Sensory sensitivities can negatively interfere with day-to-day functioning and participation in therapies and educational activities. Occupational therapists can work with a child and their family to gradually expose the child to sensory challenges and support them in learning strategies to cope with it.²² The evidence-based Ayres Sensory Integration⁶⁴ approach uses individually customized activities to support sensory processing, motor planning, movement, and organization in space, and “just right” challenges to help children process and tolerate sensory information from their body and the environment (visual, auditory, tactile, proprioceptive, and vestibular).³

Case presentation #1: preschool-aged child with autism, delays in communication and adaptive skills, and behavior challenges.

Henry is a 4-year-old boy who was diagnosed with ASD and global developmental delay at the age of 2 years. He has minimal verbal language and only uses a few single words for requesting. He is not toilet trained. He has sensory aversions, especially related to toothbrushing and feeding. He has 10 foods that he eats consistently. Henry also has difficulty with transitions which often cause him to have a meltdown (eg, dropping to the floor, screaming, and throwing things). He was enrolled in EI services when he was 18 month old. After his diagnosis of autism, he also received outpatient speech therapy and OT. His parents tried to enroll him in ABA therapy but were not successful due to long waitlists for ABA programs in their community. Since turning 3 years old, he has been enrolled in an EIBI preschool program. In the classroom, he is using PECS and more single words to communicate. Initially he handled transitions well in the classroom, although transitions continued to be a challenge at home. However, recently he has been having more meltdowns at school. His teachers describe him as seeming more irritable. Henry and his parents are currently concerned that his behavioral meltdowns have become more frequent both at home and at school.

Clinical question.

What additional questions would you ask Henry’s parents about his behavior? What guidance would you offer them?

Case discussion.

This case illustrates some of the challenges that parents of preschool-aged children with ASD face in navigating behavior. The history shared by Henry’s parents indicates that he had frequent meltdowns, but they have acutely worsened and are now occurring more frequently at his preschool. It is helpful to think about antecedents or triggers for these meltdowns and it may even be helpful for school personnel to conduct a FBA. For example, in preschool, was there a change in classroom staffing, structure, or routine? Was there recently an extended school holiday (ie, winter break)? Henry’s parents responded “no” to these questions and also noted that his daily routine at home is unchanged. Medical factors like dental cavities or constipation can cause discomfort and pain, which, in turn, can result in behavior changes in a child with limited verbal language. Henry’s parents explain that he has always been a picky eater. They worry about his nutrition and fiber intake. Usually, he has bowel movements about 2 to 3 times a week, but it has been less frequent in the last month (1–2 times a week). You determine he has constipation and recommend a bowel clean out and use of a daily stool softener. You also discuss the use of visual supports to help with understanding the structure of his day and up-coming transitions. For example, a “first, then” board could help Henry transition to a non-preferred task (eg, get shoes on and get in the car to drive to school) and then be rewarded with a preferred activity (eg, looking at a book about vehicles).

Treatment recommendations

• Continue use of daily stool softener for constipation and monitor symptoms.

• Consider referral for feeding therapy with OT or psychology to work on expanding Henry’s food repertoire.

• Continue participation in EIBI program. Discuss Henry’s behavior concerns at home with EIBI team for suggestions of strategies that have been helpful at school and could be generalized to the home setting.

• Continue use of visual support strategies, such as “first, then” board and visual schedule to help Henry prepare for transitions and increase his communication skills.

• Consider referral for speech therapy to assist parents with understanding how to build communication skills at home.

Case presentation #2: school-aged child with autism and executive functioning difficulty.

Leo is a 10-year-old male in the fourth grade who was diagnosed with autism at 4 years of age. He also has a diagnosis of ADHD-combined type and takes a stimulant medication. Leo has an IEP at school and receives speech-language therapy to address social communication difficulties (eg, asking for help, initiating interactions with peers) and OT (eg, coping with changes in his schedule, managing his emotions by taking a break). His cognitive abilities are in the low average range and he struggles with reading comprehension, which is impacting his ability to do well in school and complete homework on his own. He currently struggles with having back-and-forth conversations with peers and adults and wants to have friends, but he struggles to interact with peers at school and at baseball. Leo is very interested in video games, prefers to talk about this topic with others, and wants to play video games whenever he has free time at home. Leo has executive functioning difficulties (eg, organizing materials, planning, and prioritizing tasks). His daily living skills are below average for his age in that he still needs a lot of assistance and prompting to do simple chores (eg, clean his room, put belongings away) and personal hygiene tasks (eg, shower, brush teeth). Leo struggles to cope with his emotions at home and school such that he yells and cries when he is feeling overwhelmed, or when he does not get what he wants.

Clinical question.

What types of interventions would be helpful for optimizing Leo’s academic success, emotional functioning, and independent living skills?

Case discussion.

This case illustrates that children with autism benefit from a multidisciplinary intervention approach. This child in the case is receiving school-based services through an IEP. With an IEP, children with autism can receive educational supports for learning difficulties, in this case with reading comprehension, and related services such as speech-language therapy and OT services. An IEP for a student with Leo’s ADHD and executive functioning difficulties could also include accommodations to support slower processing time (ie, extended time on tests) and organizational difficulty (ie, use of a planner to be signed daily by his teacher). In addition to impacting his functioning in an educational setting, Leo’s autism-related challenges also affect his social and daily skills functioning at home and in the community. Therefore, Leo would also benefit from receiving outpatient therapies such as social skills training and OT or psychology treatment to support independence with daily living skills and strategies to improve executive functioning.

Treatment recommendations

After meeting with his developmental pediatrician and reviewing his current presentation and caregiver concerns, the following recommendations were made:

• Continue to receive services at school through his IEP and inquire about specific intervention to help with reading comprehension.

• Social communication—(1) enroll in a social skills group to receive instruction on specific skills, (2) set up play dates with peers he is interested in having a relationship with, to practice social skills and provide him with feedback on what he did well and what he can improve upon, (3) continue involvement in extracurricular activities.

• Executive functioning—(1) work with occupational therapist or psychologist to develop strategies that may increase his organization and planning/prioritizing skills (eg, setting up a homework routine that includes a quiet space, creating a “to-do” list of assignments in his planner, working for 20 minutes, and then taking a 5-minute break).

• Daily living skills—work with an occupational therapist or psychologist to develop a plan for building his skills by utilizing evidence-based strategies such as a task analysis (eg, break down the steps for cleaning his room and then teach him how to do each step until he is independent).

• Emotion management—work with a psychologist to develop a plan by utilizing cognitive behavioral–based strategies to increase his ability to identify and then cope with emotions (eg, take a break by going to his room and playing Legos for 5 minutes when he is overwhelmed with homework).

SUMMARY

Developmental outcomes for autistic children are optimized when a diagnosis is made at a young age (<3 years) and with prompt connection to intervention services as early as possible when a diagnosis of ASD is suspected or confirmed. Children less than 3 years of age with suspected ASD or other developmental delays should be referred to their state’s EI (part C) services, or if age 3 years or older, to their public school district (part B) for eligibility evaluation and to start services as soon as a concern is identified, even if a child has not yet completed medical diagnostic evaluations. Goals of treatment for ASD include (1) minimizing the impact of core ASD symptom–associated challenges, (2) maximizing adaptive skills and independence, and (3) reducing the impact of behaviors that negatively affect achievement of functional skills.¹⁵

Evidence-based interventions that address core ASD symptoms are categorized as either CTMs or focused intervention practices. Participation in CTMs, which generally use an ABA approach and focused intervention practices, is associated with optimal outcomes for the child. Younger age at enrollment in CTM intervention is associated with greater gains in social communication, cognitive abilities, adaptive skills, and reduction of ASD symptom severity.⁶ Children and adolescents with ASD benefit from connection to multidisciplinary professionals including speech-language pathologists, occupational therapists, and psychologists, behavior therapists, and other mental health professionals. Participation in speech-language therapy supports the development of functional communication skills through strategies such as AAC, modeling, and scripting. PEERS social skills intervention package improves adolescent social knowledge.

Challenging behavior and mental health concerns are common in autistic children and adolescents. Collaboration with psychologists and the use of FBAs can support the development of effective behavior plans to address disruptive behaviors. CBT is an effective treatment for anxiety in autistic youth without intellectual disability. Interventions that address adaptive behaviors and executive functioning promote independent living skills and success in school and work environments. Table 1 provides a summary of intervention services and therapies that may be considered to support optimal outcomes for children and adolescents with ASD.

KEY POINTS.

• Refer children with suspected autism for diagnostic evaluations and early intervention services as soon as possible.

• Participation in evidence-based interventions for autism improves outcomes across multiple domains: core autism symptoms, communication, cognition, behavior, and adaptive and social skills.

• There is no “one size fits all” approach to autism treatment—consider each child’s strengths and challenges and families’ priorities and goals.

CLINICS CARE POINTS.

• Children with suspected autism should be referred for diagnostic evaluations and EI services as soon as possible.

• Starting evidence-based EI at a young age (<3 years) is associated with greater positive impact on outcomes.

• CTM interventions are associated with improvement in core autism symptoms, cognitive abilities, communication skills, adaptive skills, and behavior.

• Consider referral for evidence-based therapies to support communication, social skills, adaptive skills, sensory processing, behavior, and mental health in children with autism, depending on each child’s strengths and challenges.

• Pediatricians play an important role in advising families about evidence-based versus non-evidence–based treatments for autism.